Elizabeth Martinez is on the faculty at Johns Hopkins University in Cardiac Anesthesia and Critical Care Medicine. Her goal is to become an independent clinician scientist focused on applying rigorous research design to quality improvement in the cardiac surgical intensive care unit (ICU), with an emphasis on evaluating processes of care that contribute to variation in outcomes in cardiac surgical patients. To realize this goal, she will enroll in a formal advanced degree program and will receive structured mentoring by senior investigators for the conduct of innovative research. The primary goal of this proposal is to determine the structure and processes of the perioperative management of patients undergoing cardiac surgery which impact on their mortality. The specific aims and related hypotheses are: 1) To identify variation in the organization of the postoperative ICU care of cardiac surgery patients through a survey of a national sample of hospitals in the State Inpatient Database (SID); 2) To obtain and evaluate discharge data for adult cardiac surgery patients in the hospitals surveyed in Aim 1 using the SID: 3) To identify the organizational characteristics and processes of care that correlate with outcomes in cardiac surgery. The candidate hypothesizes that differences in the processes of postoperative care contribute to differences in mortality in low-volume and high-volume hospitals; 4) To identify variations in the organization of care that are modifiable and associated with high performing centers but not with low performing centers. Through in-depth, on-site visits, the candidate will evaluate the current use and feasibility of implementation of the factors which were most significantly associated with improved outcomes; and 5) To disseminate the findings. Future plans are to develop a proposal to implement change, in an identified area from the analysis of Aims 1-4, at a set of hospitals with poor outcomes. It is hypothesized that, once an area is identified and change is implemented, the difference in mortality between low and high volume hospitals will be decreased. Completion of the proposed research will significantly advance our knowledge of how cardiac surgical patients are managed postoperatively and how the differences in organizational characteristics are related to their outcomes. This project will identify strategies to reduce mortality in low volume hospitals and to decrease variation in mortality within all centers, providing policy makers with data on quality and potential for system changes. These projects and the career development plan will build a foundation for a successful career as an independent investigator.